Health
is a state of mental, social and physical well-being and not merely an absence
of disease or infirmity. To achieve this noble objective, India requires health
care professionals who are trained in institutions with standardised
infrastructure, and the availability of accessible and equitable health care
for both the rural and urban populace.
Recently, the health sector has been in the
news — from the creation of a rural based graduate medical education programme,
the introduction of a common medical entrance exam, the recommendation by the
Indian Council of Medical Research (ICMR) to include cancer under notifiable
diseases, and the death of infants and children from infectious diseases. These
issues may appear very diverse from the outside but are interconnected.The
growth of medical education has been exponential, from 88 colleges in 1965, to
335 in 2011. Several more are in the pipeline. But West Bengal has fewer
colleges, completely disproportionate to the State's needs.
The non-availability of qualified faculty,
sub-standard infrastructure and clustering of medical colleges contribute to
poor training and limited exposure to clinical material. The net result is that
the outgoing ‘basic doctor' is not fully equipped to face the challenges of
ensuring ethical and safe medical practice.
Rural
based medical graduates
Recently, the number of seats in private and
public medical colleges has been doubled and efforts are on to conceptualise a
rural doctor scheme with 3{+1}/{-2}years of training to improve the
doctor-patient ratio in rural areas. Over the years, various committees — from
the Bhore committee in 1946, the Bajaj committee, the National Knowledge
Commission-2007 (NKC), headed by Sam Pitroda, to the present Medical Council of
India (MCI) Vision Documents 2011 — have made recommendations to improve the
medical and paramedical education systems. The NKC is for training existing
health care professionals and workers as multipurpose workers who will have a
thorough knowledge of the management of basic health care medical practices and
imparting health education. The creation of multipurpose health workers,
improving the role of specialist nurses and Accredited Social Health Activists
(ASHA), will provide a solution to needs in rural and underprivileged urban
pockets. A rural doctor programme signals a lot of confusion and challenges the
fundamental essence of human rights — ‘Equality.' An individual in a village
should have every right to access a well-qualified doctor just as his urban
counterpart can.
There are various paramedical courses —
nursing, physiotherapy and pharmacy with a training of four years and the MBBS
course of 5{+1}/{-2}years. In a medical hierarchical system, a doctor leads the
team, so where will a rural doctor with a training of 3{+1}/{-2}years be
positioned?
Doctors selected for the regular MBBS,
especially in public medical colleges, have maximum grades but it is uncertain
whether students applying for the rural doctor programme will be of the same
calibre. Doubling the doctor population and creating new courses alone will not
improve the standard of health care. On the other hand, it is easy access to
health care, availability of medicines, provision of clean water, sanitation
facilities, a vaccination programme similar to what is there in developed
nations, a uniform protocol-driven patient management system in certain areas
such as obstetric emergencies and medical conditions such as heart attack, and
strokes, and first aid to accident victims which will result in an improvement
of health care.
To enhance the equitable distribution of
doctors, the MCI needs to relook the methods of granting permission for new
medical colleges. When there are clear guidelines for setting up of school,
primary health centres, PDS shops and evenanganwadicentres, the MCI should, in
similar manner, formulate stringent regulations to avoid overcrowding in
medical colleges. Special incentives should be provided to encourage colleges
in rural areas, in the northeast and hilly regions. Avoiding overlapping of
medical colleges, the creation of more paramedical courses with an effective
public-private partnership model and, most importantly, the provision of urban
amenities in rural areas will pave the way for uniform distribution of doctors
and equitable health care. Irrespective of his/her geographical location, every
person needs quality health care. Therefore, it is safer to be in the hands of
a few well-qualified doctors and multipurpose workers. The NKC has provided
feasible working solutions within the existing system to increase human health
resource. Therefore one needs to question the validity of the rural doctor
training programme.
The other contentious figure is the
doctor-population ratio. In 2005, itwas 1:1,722. The present estimated ratio,
logically, should be around 1:1,450. However the MCI vision document estimates
it at 1:1,700 in 2010. The planning of health manpower varies from country to
country, and, in a country like ours, from State to State. Therefore there is a
need to create a methodology to accurately estimate the doctor-population in
accordance with our disease distribution, density of population, etc .
Entrance
test NEET
The objectives behind the National
Eligibility-cum-Common Entrance Test (NEET) are to set up a uniform standard
for basic medical education, by including nearly 15 per cent of the State's
medical seats, both private and government, under a single umbrella,
disallowing students from appearing for a number of entrance exams in order to
save time, energy and money. Premier institutions like the All India Institute
of Medical Sciences (AIIMS) and a management quota have not been included under
the NEET. Maharashtra, Tamil Nadu and Andhra Pradesh have opposed the system
because they have a well-established and acceptable selection process. As the
medical education system is a State subject, most States feel it is an
infringement on their federal rights. Certain political observers feel that the
NEET is an indirect way of diluting the reservation system that has been
implemented following the Mandal Commission's recommendations.
The NKC suggests that in the current selection
process most graduates are unlikely to serve in the rural areas as they come
from the privileged sections. The commission also indicates that “merit” is a
reason conjured to maintain the privileges within the upper crust of society.
The
larger canvas
Today, an India that is following the path of
liberalisation has made remarkable progress in various fields of science and
technology. Yet our human development indicators are among the worst in the
world — at the 119th position among 169 countries. The spectrum of diseases is
as diverse as our motherland — diabetes, hypertension, cancer, morbidity from
road traffic accidents to infectious diseases such as HIV and encephalitis. The
incidence of cancer is on the increase. Recently, the ICMR has made a strong
plea to include cancer under notifiable diseases.
The
main areas that require focus are:
The 12th Five-Year plan has proposed
increasing expenditure from one per cent of the GDP to 2.5 per cent, and this
should become a reality. It is the private sector, an inevitable permanent
feature of our health-care system, that contributes to nearly 80 per cent of
health care expenditure. Though private health care has partially alleviated
health problems, most of it is urban-centric. Recent figures suggest that 70
per cent of hospital beds are in the top 20 cities, of which 15 per cent are in
six major cities. To encourage health care investment in towns, rural, hilly
and northeastern areas, special fiscal and non-fiscal incentives should be
provided. Special tax benefits such as longer holiday periods and an exemption
from minimum alternate tax will be an impetus to private players to move away
from cities. Revisiting the Rangarajan report (criteria for infrastructure)
2001, is necessary and the Health Ministry should engage in a dialogue with
stakeholders to consider their long-term demand for the provision of an
infrastructure status to the health industry.
The implementation of universal health
insurance schemes will be a boost to the private health sector but, once again,
it is mandatory that there be just a single scheme in every State. At present,
a few State governments have successfully implemented universal health
insurance schemes. Therefore, the introduction of parallel health schemes by
the Centre for political reasons should be avoided. Instead, it should
integrate funds into the State insurance system. The universal health insurance
will pave the way for opening more hospitals in towns and villages.
Education on preventive and early diagnostic
health care should be the priority because even today hundreds of mothers and
infants die from preventable causes. Over the last few decades, the medical
field has seen newer innovations, prevented illnesses and death and increased
the lifespan. This kind of phenomenal growth is possible because health-care
professionals have moved away from their insular existence and adopted a
multidisciplinary approach. In the same way, the Health Ministry should engage
in interaction and dialogue, and formulate policies in close coordination with
the relevant departments and ministries to improve the health care system. For
example, working with the Integrated Child Development Schemes (ICDS) will help
combat malnutrition and improve maternal health care that would result in a
significant reduction in maternal and infant morbidity and mortality. Other key
ministries that can contribute to positive health outcomes include food, rural
development and environment. Poor enforcement of legislation in the food
industry — excess sugar, salt, ghee, etc, — has resulted in lifestyle diseases
such as obesity and diabetes, while increasing environmental pollution is
causing a rise in instances of cancer.
Regulation of the pharma industry, increased
funding for research and development and special incentives for medical
equipment and technology industry are other areas that need to be addressed.
Within the realms of the Health Ministry, an
area that has a system in place and working fairly effectively is medical
education. The Centre should allow every State to have its own method of
selection of candidates yet have a regulatory body to oversee the management of
the medical education system. Various committees have requested a strong
regulatory central body but its role should be limited. An MCI-like body should
only oversee the State Medical Council and have the powers to punish it in the
event of irregularities. At present, the medical education system serves two
masters — the Centre and State, leading to the present state of affairs with
nearly 54 per cent of the total number of 335 medical colleges in the southern
States.
Every person should have access to a
well-qualified basic doctor and to a health centre with adequate facilities.
India has produced world-class, health care professionals and will continue to
do so. International health tourism is in autopilot mode but we need to take
off at the national level, and plan for our millions who have inadequate and
sometimes zero access to health care. Therefore, a holistic health care policy
plan alone will take India into the league of developed nations. India can
boast of its IT revolution, has the capability to lay an FI race track and
continue its space rocket launches but all these spectacular successes will be
offset if news headlines scream of infant and maternal deaths from avoidable
causes and the arrival of killer diseases like cancer.
In 1831, Alexis de Tocqueville, an authority
on democracy, said the power of democracy lies in its tendency to centralise
power. Let's hope that the Union Ministry will disprove the Tocqueville theory,
will leave the selection of medical students to the State authority and create
innovative policies to tackle the larger issues that have to be addressed on a
war-footing.
POONGOTHAI ALADI ARUNA
The Hindu
(The author, a practising obstetrician and
gynaecologist, is a former Tamil Nadu Minister.
E-mail:poongothaibalaji@yahoo.com)
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